Free HT-209 Employe Death Benefit Report - pdf fillable format 2009 - Wisconsin

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Employe Death Benefit Report
For deaths after 12-31-91
1. Name of payor reporting 3. Name of deceased employe or former employe 5. Address of decedent 6. Type of payment reported (check only one) Annuity Pension Profit sharing Bonus 2. Name of plan

WISCONSIN DEPARTMENT OF REVENUE PO Box 8906 Madison, WI 53708-8906 Telephone (608) 266-2772

4. Date of death

Death benefit Wage Continuation Deferred compensation Date of payment

Other (explain below)

7. Amount of payment if paid in one sum

8. If payment will be made by installments, state number and amount of installments, age of beneficiary, mortality table and rate of interest used in determining the value of the installments as of date of death.

Indicate value as of date of death 9. Names and addresses of beneficiaries Relationship to decedent Share of benefits payable

10. THE BENEFITS REPORTED ABOVE ARE PAYABLE UNDER A FEDERALLY

QUALIFIED

NON-QUALIFIED

PLAN

11. If the decedent contributed to the plan or toward the benefits reported on this form, please provide the following: contributions by decedent $ contributions by employer to decedent's account $

CERTIFICATION
As representative of the payor named above, I certify that the information contained in this report is correct to the best of my knowledge and belief.
Signature Title Date

IRA or HR 10 Plan -- This form does not have to be completed to report payments from an IRA or HR 10 Plan. Section 72.34, Wisconsin Statutes provides that every person liable for paying benefits to the estate or a beneficiary of a deceased employe or former employe in the form of an annuity, bonus, pension or other benefit under a retirement, deferred compensation or profit-sharing plan taxable under this chapter, directly or through a trust or fund created by the employer for such purpose, shall give notice of such obligation to the department within 30 days following the date of payment, or the date of the initial payment if more than one payment is forthcoming, to the estate or any beneficiary of such employe or former employe.
HT-209 (R. 6-09) Wisconsin Department of Revenue